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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1117078



Case Details

VAERS ID: 1117078 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: California  
Vaccinated:2021-03-11
Onset:2021-03-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802070 / N/A LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Arteriosclerosis, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atenolol 50mg/day; unknown/various (B complex, metamucil tabs)
Current Illness: none
Preexisting Conditions: Hypertension
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient died approx. 5 hours after shot was administered. Cause of death reported is Atherosclerotic Cardiovascular Disease. The death certificate was signed by the county coroner without autopsy, based on the report by the onsite deputy coroner. No doctors or hospitals were involved. This report is FYI only; there has been no direct connection made between my mother''s death and the vaccine other than one followed shorty after the other.


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